National HACC Functional Screening Instrument

National HACC Functional Screening Instrument
Part One: Questions to ask the client (or the person who represents the client) 1 :
Unique Client ID_____________________________________
Date screened_______________________
I would like to ask you about some of the activities of daily living, things that we all need to do as part of our daily lives. I would like to know if you can do
these activities without any help at all, or if you need some help to do them, or if you can’t do them at all. The questions refer to how you are managing
at the moment.
Item Question Score Record score
1
2
3
4
5
Can you do housework…
Without help (can clean floors etc) 2
With some help (can do light housework but need help with heavy housework) 1
Or are you completely unable to do housework 0
Can you get to places out of walking distance…
Without help (can drive your own car, or travel alone on buses or taxis) 2
With some help (need someone to help you or go with you when travelling) 1
Or are you completely unable to travel unless emergency arrangements are made for a specialised vehicle
like an ambulance
Can you go out for shopping for groceries or clothes (assuming you have transportation)…
Without help (taking care of all shopping needs yourself) 2
With some help (need someone to go with you on all shopping trips) 1
Or are you completely unable to do any shopping 0
Can you take your own medicine…
Without help (in the right doses at the right time) 2
With some help (able to take medication if someone prepares it for you and/or reminds you to take it) 1
Or are you completely unable to take your own medicines 0
Can you handle your own money…
Without help (write cheques, pay bills etc) 2
With some help (manage day-to-day buying but need help with managing your chequebook and paying your
bills)
Or are you completely unable to handle money 0
Do not ask the following 2 questions if the client scored 2 on all of the above 5 items (ie, can do all 5 activities without help). Instead, for clients who
scored 2 on all of the above items, record a 9 on each of the following 2 items to indicate that you did not ask the question.
6
7
Can you walk…
Without help (except for a cane or similar) 2
With some help from a person or with the use of a walker, or crutches etc 1
Or are you completely unable to walk 0
Can you take a bath or shower…
Without help 2
With some help (eg, need help getting into or out of the bath) 1
Or are you completely unable to bathe yourself 0
0
1
NOTES:
• If unanswered, score X.
• Rate what the person is currently capable of doing rather than what they actually do. In assessing capability, take into account not only physical function but also
cognition (such as problems caused by dementia or an intellectual disability) and behaviour (such as unpredictable challenging behaviour). Consumers able to complete
a task with verbal prompting should not be rated as independent (and therefore should be rated as a 1). In rating an item that is irrelevant (for example, the person has
no shops in the vicinity or does not use any medications), rate based on what the person would be capable of doing if the item was actually relevant to their situation.
• Item 6 (walking). Clients who are in a wheelchair should be rated as (1) if they are independent including corners etc or (0) if they are not wheelchair independent.
1 Reproduced from the OARS/MFAQ. Copyright: the Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina.
Used with permission. Questions 1, 6 and 7 have been modified.
National HACC Functional Screening Tool

Part Two: Questions for you to complete
Complete the following based on all information available to you – your judgement based on interviewing or
observing the client, information contained in a referral letter, client notes or information provided by a proxy
respondent, such as a friend, relative, carer or referring agency.
Note that the client should not be asked to answer these questions.
Item Question Record score
8
Does the person have any memory problems or get confused
No – score 2
Yes – score 0
9
Does the person have behavioural problems for example, aggression, wandering or agitation
No – score 2
Yes – score 0
Recommended functional assessments based on this functional screen
Domestic
Look solely at items 1 to 5. Count the number of these items that scored 2 (ie, count the number of activities that the
person can do without help).
Refer for a domestic functional assessment if the person can do less than 3 activities without assistance – ie, the count is
2 or less (a count of 0, 1 or 2).
Self-care
Refer for a self-care functional assessment if the client SCORED LESS THAN 2 on either Item 6 (mobility) or Item 7
(bathing).
Cognition
Refer for a cognitive assessment if:
• the client scored LESS THAN 2 on either Item 4 (medicine) or Item 5 (financial management) AND you have
determined that the client has no physical disabilities or problems with English literacy that may account for the client
not being independent on these items OR
• the client scored 0 on Item 8.
Behaviour
Refer for a behavioural assessment if:
• the client scored LESS THAN 2 on either Item 4 (medicine) or Item 5 (financial management) AND you have
determined that the client has no physical disabilities or problems with English literacy that may account for the client
not being independent on these items OR
• the client scored 0 on Item 9.
National HACC Functional Screening Tool